Dermal fillers and augmentation procedures

What are dermal fillers?

Dermal fillers and other implants are used for facial augmentation. They can be chosen for reconstructive or cosmetic purposes. It has become increasingly popular for the ‘normal’ everyday person to seek dermal fillers to fill in acne scars and facial lines or to enhance a specific facial area. Dermal fillers are injected just below the skin surface. Other materials are implanted in the subcutaneous area to restore or replace fat.

Over the years, many filling agents have been developed. However, the search is still on for the ideal facial implant material. The ideal product should have the following properties:

• Physiologically acceptable: incorporates itself with the body's tissues
• Free of complications or side effects
• Permanent: does not degrade with time
• Easy to use: simple and quick procedure, that is, injectable.

What are dermal fillers and other implants used for?

Dermal fillers and facial implants can be used in reconstructions for areas that may have been scarred or altered by trauma. This may be done in conjunction with minor or major plastic surgery. The other increasing use of dermal fillers is in cosmetic surgery where patients seek these treatments to improve their appearance.

They are mainly used for the removal or improvement of scars caused by acne, correction of facial (wrinkle) lines, and enhancement or filling in of certain specific facial features such as the lips or chin.

What products are available?

There are numerous substances that add bulk to tissue. Each has its place and specific uses in facial augmentation. See individual implant types for specific details regarding use. The list below includes some older products that are no longer in general use.

Of the implant types described above, the following are injectable augmentation products:

• Collagen (excluding Alloderm®)
• Hyaluronic acid
• Polymethyl-methacrylate (PMMA)
• Hydrophilic polyacrylamide gel
• Poly-L-lactic acid.

These products provide facial augmentation with less downtime. Collagen and hyaluronic acid provide only a temporary solution as they are reabsorbed into the body over time (3–12 months); top-up treatments are necessary to maintain the desired correction. PMMA and hydrophilic polyacrylamide gel are recent additions of injectable augmentation products and give more long-lasting results (months to years).

Are there any side effects from using facial implants?

All dermal fillers and facial implants currently used have some side effects that preclude them from being the ideal agent. Some of the side effects and complications that may occur include:

• Tenderness, bleeding and bruising
• Lumps, nodules, overcorrection, blue appearance from too superficial injection
• Allergic reactions
• Non-allergic inflammatory reactions eg granulomatous reactions weeks to years after injection: nonpainful lumps
• Numbness due to nerve palsy
• Vascular injury
• Infections: reactivation of herpes virus, staphylococcal infection, infectious granulomas and biofilms
• Movement or extrusion of implant.

See individual implant types for specific problems.

Prevention of side effects from dermal fillers

Proper knowledge of facial anatomy, training in injection technique and supervision of new injectors will reduce the risks.

• Caution is necessary for any injection in patients with a history of bleeding disorder or taking aspirin, warfarin, ginseng, vitamin e or other anticoagulant agent.
• Prophylactic antivirals, such as oral aciclovir, should be prescribed if there is a history of herpes infection (cold sores).
• Lumps can be removed by puncturing the overlying skin to squeeze out the gel, injecting hyaluronidase to dissolve filler with massage to spread it out.
• Minimise filler in thin skinned areas, such as tear trough, eyelids, and lips.
• Avoid intravascular injection in glabella and nasolabial folds (because of limited collateral circulation); aspirate prior to injection, use tiny amounts of filler, and inject superficially.